eMedicine Specialties > Pulmonology > Obstructive Airways Diseases

Status Asthmaticus: Follow-up

Author: Constantine Saadeh, MD, Chief, Department of Internal Medicine, Northwest Texas Hospital; President, Allergy ARTS, LLP; Clinical Professor, Departments of Internal Medicine, Pediatrics, Microbiology, and Immunology, Texas Tech Health Science Center
Contributor Information and Disclosures

Updated: Jun 4, 2009

Follow-up

Further Inpatient Care

  • Sedatives
    • Patients may benefit from sedatives in very small doses and under controlled, monitored settings. Sedatives should be used judiciously, if at all. For example, lorazepam (0.5 or 1 mg intravenously) could be used for patients who are very anxious and are undergoing appropriate and aggressive bronchodilator therapy.
    • More powerful agents (eg, oxybutynin) can be administered to intubated patients to achieve sedative, amnestic, and anxiolytic effects.
  • Mechanical ventilation
    • Consider mechanical ventilation as a last resort in patients with status asthmaticus.
    • Mechanical ventilation in patients with asthma requires careful monitoring because these patients have high end-expiratory pressure and, therefore, are at very high risk for pneumothorax.
    • Mechanical ventilation, when used in patients with asthma, is usually required for less than 72 hours; however, in occasional patients with severe bronchospasm, mechanical ventilation can be prolonged. In these situations, consultation with a pulmonologist or another expert in mechanical ventilatory techniques is likely useful.
    • Ram et al27 have shown noninvasive positive pressure ventilation to be affected by meta-analysis.
    • Ueda et al28 reported using noninvasive positive pressure ventilation to wean a patient with refractory status asthmaticus who also had developed atelectasis.
    • Leatherman et al29 reported that prolongation of the expiratory time can decrease dynamic inflation in patients with status asthmaticus and may have a minor positive effect on weaning in these patients.
  • Other treatments
    • Other treatments have been used, but none is well proven in patients with severe acute asthma.
    • A combination of helium and oxygen known as heliox (ie, 30/70 mixture) has been used, but this treatment should only be considered in patients who are able to take deep breaths because the treatment is dependent on inspiratory flow.30
    • Intravenous magnesium sulfate can be tried, especially in pregnant women, as an adjunct to beta-2 bronchodilator therapy.
    • Nitrate oxide has been tried in a child with refractory asthma. The future role of this therapy remains to be determined.
    • Leukotriene modifiers are useful for treating chronic asthma but not acute asthma. This treatment may be beneficial if used via a nebulizer, but it remains experimental.
  • Hydration
    • Hydration, such as normal saline at a reasonable rate (eg, 150 mL/h), is essential.
    • Special attention to the patient's electrolyte status is important.
    • Hypokalemia may result from either steroid use or beta-agonist use. Correcting hypokalemia helps wean an intubated patient with asthma. Hypophosphatemia may result from poor oral intake and is also an important consideration when weaning such patients.
  • Intravenous antibiotics
    • Intravenous antibiotics are important in patients with acute asthma only if they have evidence of an infection (eg, pneumonia, sinusitis).
    • In some situations, sinus imaging using CT scanning or plain radiography31,32 may be essential to help rule out chronic sinusitis.

Further Outpatient Care

  • Instruct patients to use of inhalers appropriately, to be compliant with therapy, and to practice stress-avoidance measures. Stress factors (ie, triggers of asthma attacks) include pet dander, house dust, and mold. Strongly discourage patients from smoking; this practice should be avoided at all costs. Finally, appropriate follow-up is important, as is checking the patient's peak flow meter and FEV1 at home or in the office, respectively.
  • Children with asthma commonly present with normal FEV1, and, accordingly, more sensitive lung function testing should be undertaken with regular IOS assessments. Medication titration may be usefully guided by IOS resistance and reactance values.
  • Identify specific patients who are at risk for asthma exacerbation, such as younger children and adults older than 60 years. A retrospective analysis,33 has shown that the severity of asthma at baseline and the age of the patient are the most important determining factors in the risk for recurrent status asthmaticus and for predicting the severity of the attack. In other words, patients older than 60 years who are also characterized as having either moderate persistent asthma or severe persistent asthma are at higher risk of developing status asthmaticus. Therefore, compliance with the National Institutes of Health (NIH) guidelines for the treatment and management of patients with asthma should theoretically be an effective prophylaxis against the development of status asthmaticus.

Deterrence/Prevention

  • Status asthmaticus can be prevented if patients are compliant with their medications and they avoid stress factors; however, it can occur even when patients are compliant and doing well as outpatients. In such situations, search for an occult infection (eg, RSV in children but rarely in adults; occult sinus infection).
  • Prevention of status asthmaticus may be aided by monitoring forced oscillation test results rather than spirometry findings. This is particularly true for children younger than 12 years; however, adults with reactive airways may be undertreated if the criterion for stability and normality is a spirometric FEV1 greater than 80% of the predicted value.

Complications

  • Pneumothorax may complicate acute asthma, either because of increased airway pressure or as a result of mechanical ventilation. Superimposed infection can also occur in intubated patients. Patients may require a chest tube for pneumothorax or aggressive antibiotic therapy for a superimposed infection.

Prognosis

  • In general, unless a complicating illness such as congestive heart failure or chronic obstructive pulmonary disease is present, with appropriate therapy status asthmaticus has a good prognosis. A delay in initiating treatment is probably the worst prognostic factor. Delays can result from poor access to health care on the part of the patient or even delays in using steroids. Patients with acute asthma should use steroids early and aggressively.

Patient Education

  • One important aspect of patient education is that asthma is a disease of airway inflammation; it is not simply bronchospasms. Airway inflammation is a continuing process that renders patients with asthma vulnerable to acute bronchospasms. Symptoms are more dependent on bronchospasms than on inflammation; thus, symptoms may become minimal in the presence of continued peripheral airway inflammation. Because patients often wish to discontinue inhaled corticosteroids when they are free of acute bouts of wheezing, educating them regarding the need for controller medications to minimize peripheral airway inflammation is important.
  • Patients can be shown the results of forced oscillation testing that occur with peripheral airway inflammation and obstruction. Review the test results with patients and show them the improvement with inhaled corticosteroids and the deterioration when they are not compliant with anti-inflammatory medications. This information may materially enhance patients' awareness of the need for continuing treatment, despite an absence of wheezing.
  • For excellent patient education resources, visit eMedicine's Asthma Center. Also, see eMedicine's patient education articles, Asthma, Asthma FAQs, and Understanding Asthma Medications.

Miscellaneous

Medicolegal Pitfalls

  • Failure to initiate steroid therapy or intubation with mechanical ventilation
  • Failure to obtain sinus imaging or to monitor the patient's electrolyte balance
  • Failure to admit a wheezing patient with a normal PCO2: Such patients typically have respiratory muscle fatigue and require hospital admission.
  • Failure to treat expediently, especially with bronchodilators
  • Failure to educate patients upon discharge about the appropriate use of their inhalers, the importance of therapy compliance, and the efficacy of stress-avoidance measures

Special Concerns

  • Treat pregnant women with acute asthma in the same aggressive manner as nonpregnant women. Respiratory acidosis can be detrimental to both the fetus and the mother. Use special abdominal shielding during chest radiography or sinus imaging.
  • Treat children with acute asthma in manner similar to that for adults, except when children are mechanically ventilated, because their chests are more compliant and require special attention.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Michael Goldman, MD, and Jan Malacara, PA-C, to the development and writing of this article.



More on Status Asthmaticus

Overview: Status Asthmaticus
Differential Diagnoses & Workup: Status Asthmaticus
Treatment & Medication: Status Asthmaticus
Follow-up: Status Asthmaticus
References
Further Reading
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References

  1. Han P, Cole RP. Evolving differences in the presentation of severe asthma requiring intensive care unit admission. Respiration. Sep-Oct 2004;71(5):458-62. [Medline].

  2. Hanania NA, David-Wang A, Kesten S, Chapman KR. Factors associated with emergency department dependence of patients with asthma. Chest. Feb 1997;111(2):290-5. [Medline].

  3. Rodrigo GJ, Rodrigo C. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emerg Med J. Jun 2005;22(6):404-8. [Medline].

  4. {Guideline} National Heart, Lung, and Blood Institute. Managing exacerbations of asthma. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. National Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=11678&nbr=006027&string=asthma. Accessed August 2008.

  5. Spahn JD, Cherniack R, Paull K, Gelfand EW. Is forced expiratory volume in one second the best measure of severity in childhood asthma?. Am J Respir Crit Care Med. Apr 1 2004;169(7):784-6. [Medline].

  6. Goldman MD, Carter R, Klein R, Fritz G, Carter B, Pachucki P. Within- and between-day variability of respiratory impedance, using impulse oscillometry in adolescent asthmatics. Pediatr Pulmonol. Oct 2002;34(4):312-9. [Medline].

  7. Marotta A, Klinnert MD, Price MR, Larsen GL, Liu AH. Impulse oscillometry provides an effective measure of lung dysfunction in 4-year-old children at risk for persistent asthma. J Allergy Clin Immunol. Aug 2003;112(2):317-22. [Medline].

  8. Ducharme FM, Davis GM. Measurement of respiratory resistance in the emergency department: feasibility in young children with acute asthma. Chest. Jun 1997;111(6):1519-25. [Medline].

  9. Ducharme FM, Davis GM. Respiratory resistance in the emergency department: a reproducible and responsive measure of asthma severity. Chest. Jun 1998;113(6):1566-72. [Medline].

  10. Skloot G, Goldman M, Fischler D, Goldman C, Schechter C, Levin S, et al. Respiratory symptoms and physiologic assessment of ironworkers at the World Trade Center disaster site. Chest. Apr 2004;125(4):1248-55. [Medline].

  11. Saadeh CK, Goldman MD, Gaylor PB. Forced oscillation using impulse oscillometry (IOS) detects false negative spirometry in symptomatic patients with reactive airways. J Allergy Clin Immunol. 2003;111:S136.

  12. Newman LJ, Richards W, Church JA. Isoetharine-isoproterenol: a comparison of effects in childhood status asthmaticus. Ann Allergy. Apr 1982;48(4):230-2. [Medline].

  13. Haskell RJ, Wong BM, Hansen JE. A double-blind, randomized clinical trial of methylprednisolone in status asthmaticus. Arch Intern Med. Jul 1983;143(7):1324-7. [Medline].

  14. Press S, Lipkind RS. A treatment protocol of the acute asthma patient in a pediatric emergency department. Clin Pediatr (Phila). Oct 1991;30(10):573-7. [Medline].

  15. Heshmati F, Zeinali MB, Noroozinia H, Abbacivash R, Mahoori A. Use of ketamine in severe status asthmaticus in intensive care unit. Iran J Allergy Asthma Immunol. Dec 2003;2(4):175-80. [Medline].

  16. Elliot S, Berridge JC, Mallick A. Use of the AnaConDa anaesthetic delivery system in ICU. Anaesthesia. Jul 2007;62(7):752-3. [Medline].

  17. Burburan SM, Xisto DG, Rocco PR. Anaesthetic management in asthma. Minerva Anestesiol. Jun 2007;73(6):357-65. [Medline].

  18. Rishani R, El-Khatib M, Mroueh S. Treatment of severe status asthmaticus with nitric oxide. Pediatr Pulmonol. Dec 1999;28(6):451-3. [Medline].

  19. Mroueh S. Inhaled nitric oxide for acute asthma. J Pediatr. Jul 2006;149(1):145; author reply 145. [Medline].

  20. Mikkelsen ME, Pugh ME, Hansen-Flaschen JH, Woo YJ, Sager JS. Emergency extracorporeal life support for asphyxic status asthmaticus. Respir Care. Nov 2007;52(11):1525-9. [Medline].

  21. [Guideline] Dombrowski MP, Schatz M; ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin: clinical management guidelines for obstetrician-gynecologists number 90, February 2008: asthma in pregnancy. Obstet Gynecol. Feb 2008;111(2 Pt 1):457-64. [Medline].

  22. Schultz TE. Sevoflurane administration in status asthmaticus: a case report. AANA J. Feb 2005;73(1):35-6. [Medline].

  23. Glover ML, Machado C, Totapally BR. Magnesium sulfate administered via continuous intravenous infusion in pediatric patients with refractory wheezing. J Crit Care. Dec 2002;17(4):255-8. [Medline].

  24. Scarfone RJ, Loiselle JM, Joffe MD, Mull CC, Stiller S, Thompson K, et al. A randomized trial of magnesium in the emergency department treatment of children with asthma. Ann Emerg Med. Dec 2000;36(6):572-8. [Medline].

  25. Bessmertny O, DiGregorio RV, Cohen H, Becker E, Looney D, Golden J, et al. A randomized clinical trial of nebulized magnesium sulfate in addition to albuterol in the treatment of acute mild-to-moderate asthma exacerbations in adults. Ann Emerg Med. Jun 2002;39(6):585-91. [Medline].

  26. [Best Evidence] Blitz M, Blitz S, Beasely R, Diner BM, Hughes R, Knopp JA, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev. Oct 19 2005;CD003898. [Medline].

  27. Ram FS, Wellington S, Rowe BH, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. Jan 25 2005;CD004360. [Medline].

  28. Ueda T, Tabuena R, Matsumoto H, Takemura M, Niimi A, Chin K, et al. Successful weaning using noninvasive positive pressure ventilation in a patient with status asthmaticus. Intern Med. Nov 2004;43(11):1060-2. [Medline].

  29. Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. Jul 2004;32(7):1542-5. [Medline].

  30. Shiue ST, Gluck EH. The use of helium-oxygen mixtures in the support of patients with status asthmaticus and respiratory acidosis. J Asthma. 1989;26(3):177-80. [Medline].

  31. Fuller CG, Schoettler JJ, Gilsanz V, Nelson MD Jr, Church JA, Richards W. Sinusitis in status asthmaticus. Clin Pediatr (Phila). Dec 1994;33(12):712-9. [Medline].

  32. Sacha RF, Tremblay NF, Jacobs RL. Chronic cough, sinusitis, and hyperreactive airways in children: an often overlooked association. Ann Allergy. Mar 1985;54(3):195-8. [Medline].

  33. Oguzulgen IK, Turktas H, Mullaoglu S, Ozkan S. What can predict the exacerbation severity in asthma?. Allergy Asthma Proc. May-Jun 2007;28(3):344-7. [Medline].

  34. Ciccolella DE, Brennan K, Kelsen SG, Criner GJ. Dose-response characteristics of nebulized albuterol in the treatment of acutely ill, hospitalized asthmatics. J Asthma. Sep 1999;36(6):539-46. [Medline].

  35. Mathison DA. Asthma in Adults, Evaluation and Management. In: Middleton E Jr, Reed CE, Ellis EF, Adkinson NF Jr, Yunginger JW, Busse WW, eds. Allergy Principles & Practice. 5th ed. St. Louis, Mo: Mosby-Year Book; 1998:901-20.

  36. Patterson R, Grammar LC, Greenberger P, eds. Status Asthmaticus. In: Allergic Diseases: Diagnosis and Management. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:529-42.

  37. Richards W. Hospitalization of children with status asthmaticus: a review. Pediatrics. Jul 1989;84(1):111-8. [Medline].

  38. Schwartz HJ, Thompson JS, Sher TH, Ross RJ. Occult sinus abnormalities in the asthmatic patient. Arch Intern Med. Dec 1987;147(12):2194-6. [Medline].

  39. Sthoeger ZM, Eliraz A, Asher I, Berkman N, Elbirt D. The beneficial effects of Xolair (omalizumab) as add-on therapy in patients with severe persistent asthma who are inadequately controlled despite best available treatment (GINA 2002 step IV)--the Israeli arm of the INNOVATE study. Isr Med Assoc J. Jun 2007;9(6):472-5. [Medline].

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Further Reading

Asthma Resources from Medscape and eMedicine
Asthma News and Articles

Asthma Clinical Reference

Asthma CME

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Keywords

status asthmaticus, asthma, asthma treatment, asthma children, acute asthma, hyperactive airway disease, asthma, asthma emergency, allergen exposure, respiratory tract infection, pollen, mold, animal dander, house dust mites, wheezing, chest tightness, progressive shortness of breath, dry cough, viral respiratory illness, underuse of anti-inflammatory therapy, allergic bronchopulmonary aspergillosis, Churg-Strauss vasculitis, beta-agonists, theophylline, bronchoconstrictive response, broncho-constrictive response, peripheral airway inflammation, bronchodilator therapy

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Contributor Information and Disclosures

Author

Constantine Saadeh, MD, Chief, Department of Internal Medicine, Northwest Texas Hospital; President, Allergy ARTS, LLP; Clinical Professor, Departments of Internal Medicine, Pediatrics, Microbiology, and Immunology, Texas Tech Health Science Center
Constantine Saadeh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Rheumatology, American Medical Association, Southern Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Helen M Hollingsworth, MD, Director, Adult Asthma and Allergy Services, Associate Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, Boston Medical Center
Helen M Hollingsworth, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American Thoracic Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregg T Anders, DO, Medical Director, Great Plains Regional Medical Command , Brook Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio
Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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